sexual abuse

I was approached by a med-tech start-up company regarding their self-collection device for at-home screening “to prevent cervical cancer and Pelvic Inflammatory Disease (PID)”. The Eve Kit’s promo video and Indiegogo funding campaign explains the device and their motivation for designing it.

Violeta Cobo, Territory Manager, said that “HerSwab™ (the device that collects the sample) has been approved for self-collection of cervico-vaginal samples” by Health Canada. The device is to be launched in late 2016.

The promo video raised a number of questions for me.

The device was registered with Health Canada for “safety, efficacy and intended use”, but as I explained to Jessica Ching, co-founder and CEO, the term “approved” is open to interpretation.

But that was only a quibble.

How exactly did they intend to test for cancer, HPV and “STIs which could cause PID”? Was the device a Pap test? An HPV DNA test? A swab for chlamydia and gonorrhea?

Ms. Ching explained that the device is not a Pap test. It can sample for either HPV or gonorrhea and chlamydia depending on which test the woman prefers. To detect HPV, the device collects the sample from the upper vaginal canal. The lab uses PCR amplification to test for high-risk strains of HPV.

However, because Pap tests use cytology when they sample from the cervix, I expressed some concern in case the self-sample result was inaccurate. A meta-analysis concluded that self-sampling and physician sampling were equivalent; but studies are ongoing.

Regarding the self-sample for chlamydia and gonorrhea a small study (189 women) found their swab for “easy, comfortable” and “suitable for diagnosis”.

As to what happens after diagnosis, Ms. Cobo responded:

“When a patient gets a positive result, she gets referred to one of the doctors we are going to work with. The doctor will follow up with her and prescribe treatment or refer to a screening visit (in case of HPV) if needed. She could also grant us permission to share the results with her family doctor if she has one.”

However, when I asked about the availability of those doctors, Ms. Ching admitted that to date there were very few with whom they have been able to partner. The ideal, she added, would be to eventually offer follow-up across the country; however, one of the rationales for the product is precisely the dearth of health care providers.

Do women want to do it for themselves?

The promotional material for the $85.00 kit argues that women find testing “awkward” and that they may not have time to see a health professional. They also see at-home privacy as a plus.

I asked Ms. Ching about research they had done into whether and why women would prefer at-home testing. They did focus groups with 20 women and spoke with 50 others from whom they gathered anecdotal information. She also mentioned focus groups conducted by the Dalla Lana School of Public Health and St. Michael’s hospital and commented, “Our informal findings did mirror the findings of other published studies”. A CMAJ commentary asks whether the time for self-testing in Canada has come.

The CMAJ commentary poses the question from a public health point of view about women at risk in Canada who might truly benefit.

In Australia, self-testing will be available in 2017 – to targeted women. For me, this is the real public health issue. In Australia,

“Women who don’t normally get pap smears – including indigenous women, victims of sexual abuse and those who avoid the test for cultural or religious reasons – have the highest rates of cervical cancer. These are the women who, from 2017, will be able to collect their own tissue samples in world-first changes to the country’s screening program”.

Targeted self-testing strikes me as an improvement on the selling points of awkwardness, privacy and time constraints.

In Canada as in Australia, the women who get cervical cancer are not screened regularly and/or do not have follow-up and treatment for abnormal Pap tests. They are poor, marginalized and Indigenous. The Canadian government’s response has been expensive vaccinations for girls (and in some provinces, boys) against HPV. Women’s health advocates would prefer to see better access to screening and follow-up through Pap registries; and improved access to health care, especially in remote areas. According to the CMAJ commentary, some pilot testing of self-sampling has already taken place for these high-risk women.

The value of health professionals

As someone who worked in a sexual health clinic as a counsellor for three decades, I have one more issue.

When a woman came in for testing, I explained the Pap test, what it was for and how it was done. In fact, I often accompanied her to the examining room to translate (Spanish, French and occasionally very inadequate Portuguese) and in some cases, to hold her hand, especially when there had been past sexual trauma.

Counsellors use an intake sheet which covers not just medical, but also sexual history. We find out if the woman has a history of sexual abuse, if she has been having unprotected sexual activity, if it was vaginal, anal or oral, if she understands the difference between the Pap test and STI testing. We find out which STI she should be tested for depending on her risk factors. We tell her about contact tracing in case we find a reportable STI. We explain that HPV is very common and that only certain types may lead to cervical cancer unless the abnormal cells are treated.

These conversations are critical in helping a woman take control of her health in a way that DIY testing cannot.

Given the cost and limitations, it remains to be seen what role self-testing might play in this country.

A recent story about a spike in Sexually Transmitted Infections (STIs) in Alberta piqued my interest, not so much because of the increase, but the reaction to it. The Alberta Chief Medical Officer of Health, Dr. Karen Grimsrud, blamed “apps”: “We believe this is due to use of social media to set up sexual encounters,” she said, and added that social media tools are helping people communicate quickly to arrange anonymous sexual encounters. While I agree with her follow-up statement – that anonymous encounters make it difficult to contact people for testing and treatment – I cannot join her in blaming a social media platform for a complex social issue.

While it is true that apps make casual sexual relationships more accessible, you still have to make a decision about what’s going to happen – and how – whether you meet in a bar; or whether you meet online through a dating site or app. Human behaviour is complicated; and human sexual behaviour is especially complicated when it comes to risk-taking. Any sexual relationship, be it a one-time hook-up or longer term, requires clear communication. Consent – ongoing, affirmative consent about the sexual activities that will occur should be established; and the level of safety with which both people are comfortable should be negotiated. Should.

And yet, communication and negotiation are not always straightforward. The result is risky behaviour.

The social determinants of health influence risk-taking. Poverty, for example, is associated with increased risk-taking. In my city, one can map the curve of teen pregnancy and STIs through the poorer neighbourhoods. Internalized homophobia, current or previous abuse may also prevent a person’s ability to be assertive about safer sex because of low self-worth.

Most STIs show no symptoms. To be blunt, if you have had unprotected sexual activity, you need to be tested. But you will not necessarily get an HIV test for example, unless you specifically ask for it. That means you have to actually disclose your unsafe sexual practices. Bacterial infections can be cured with antibiotics, but viral infections, although treatable, generally stay in the body. The exception is Human Papillomavirus (HPV) which clears in the majority of cases.

Women may falsely believe they are protected because they have regular Pap tests. But they are unaware that the Pap only looks for unusual cells on the cervix: it does not test for STIs.

Men may avoid testing because they are afraid they will be swabbed for Chlamydia and gonorrhea; clinics generally do a urine test.

There is no test for (HPV) or a screening test for herpes. You have to show your bump or sore to a doctor. You may not even notice a sore on, around or inside the genitals, especially if it goes away.

Some people want testing so they can stop using barrier protection for vaginal or anal sex. One of the reasons for an increase in chlamydia among young heterosexuals is that he drops the condom before testing once she starts using the Pill.

After testing, a couple can negotiate the sexual activities they are willing to have without protection. If someone has a history of cold sores, for example (caused by herpes simplex virus – 1), they should tell their partner before offering unprotected oral sex. (In the absence of a sore, one can still transmit HSV-1.)

Public Health initiatives

After the first Alberta STI spike in 2013, they came up with sexgerms.com . “Plenty of syph” received a lot of attention, much of it negative. The site has since been revised. But it still refers, as do most educational materials, to “sex” rather than higher and lower risk sexual activities. Moreover, the assumption is that “sex” means penis in vagina intercourse. Skin-to-skin contact in the “boxer short area” is enough to spread HPV and HSV -1 and -2.

Since we’re not going to plastic wrap our entire bodies, there is always some risk involved.

But health authorities are not always realistic. Dr. James Talbot, former Chief MOH of Alberta interviewed during the 2015 STI spike called for:

no unprotected sex

abstinence

mutual monogamy

condoms

This is not a risk reduction strategy.

There is no point encouraging unrealistic, unattainable goals. In 30 years of clinic work, I can count a handful of people who used condoms for oral sex, most of whom were sex workers. So when I talked with men who had sex with men, I explained that if they were having multiple oral sex partners and not using condoms, they needed to be tested more frequently for syphilis, which could be treated and cured. This is a concrete way to prevent HIV transmission.

Older folks get frisky, too

The Current discussion touched on seniors and safer sex. The statistics for seniors are becoming alarming. Statistics show increases in incidents of syphilis, chlamydia and gonorrhea in adults 45-64. Alex McKay of SIECCAN mentioned an ongoing study of middle aged Canadians, indicating that condom use for this group is “staggeringly low”.

Older people may be even less able to communicate about STIs than teenagers or young adults. Heterosexuals may have used condoms in the old days for pregnancy protection, rather than out of concern for STIs. They may (erroneously) assume that a new sexual partner was monogamous during their former long-term relationship. They may also be learning the dating game the “hard” way. A 2010 study discovered that men who use erectile dysfunction drugs such as Viagra have higher rates of STIs in the year before and after use of these drugs.

Older women whose vaginas may have lost elasticity and the ability to lubricate may be at higher risk for STIs including HIV. Potential abrasions during vaginal intercourse may allow the entrance of viruses and bacteria. Prolonged vaginal intercourse with a Viagra inspired partner may not help either.

True prevention

Rather than app bashing or unrealistic expectations, let’s just apply good old public health policy.

Pregnancies to teenagers and “unmarried women who had not finished high school” plunged, especially in the poorest areas of the state, allowing them time, according to the article, to “gain a foothold in an increasingly competitive job market”. It was seen as a poverty reduction strategy.

I wish I had been a fly on the wall during the counselling sessions that led these young and poor Colorado women to choose long-acting contraceptives. Were they fully briefed on the side effects and potential risks? Did they discuss Sexually Transmitted Infection (STI) prevention? What was the overall vision of poverty reduction in Colorado?

During my sexual health clinic days, there were women who chose – and continued to use – Depo Provera, a contraceptive injection that lasts for three months. They did so after I had fully informed them of potential side effects and risks of the progesterone-only method. Some adolescents who came to the clinic were good candidates for the copper IUD and it worked very well for them. After a clinic counselling session, when young teens or disadvantaged women opted for a method of birth control that worked for them; or they chose to end a pregnancy realizing that their circumstances would not allow them to raise a child at that time, they were making informed choices. I recognized then as I do now, that reproductive control and poverty, while linked, are not the only elements in the equation. After reading the article, I wondered about other measures proposed to reduce poverty in Colorado; and what will happen when the private grant to fund this experiment runs out.

Teenage pregnancy and pregnancy for low income women are complex issues. Factors that result in unplanned pregnancies to teenagers include lower economic status, sexism, racism, prior sexual abuse and ongoing abusive relationships. The absence of the social determinants of health can result in risk-taking behaviours, like smoking and unprotected sexual activity. With regard to sexual abuse, for example, without the benefit of comprehensive counselling, young women run the risk of future sexual assault and abusive, controlling partners. Some exploitative male partners will refuse to “allow” them to use contraception; or they may refuse to use condoms. When one has little control in one’s life, reproductive control is not even on the table.

For younger and poor women, while it may not be prudent financially, emotionally or even physically to continue a pregnancy, if poverty itself were eradicated, part of the burden to the state would be eliminated, while still allowing funding to provide parenting support.

I imagine some ideological detractors of the Colorado experiment might accuse them of eugenics, deliberately limiting births to racialized and poor women. I do not subscribe to this point of view. However, one must acknowledge the history of eugenics practices in North America and abroad that will inevitably make some people skeptical of the motivation behind this poverty reduction experiment.

And yet, research is conflicting on the relationship between teen pregnancy and poverty. According to Statistics Canada, “women from disadvantaged backgrounds are more likely to end up disadvantaged even if they delay childbearing. And while teenage childbearing continues to be a significant indicator of lower socioeconomic outcomes, the effect is smaller than originally believed” (http://www.statcan.gc.ca/pub/75-001-x/2008105/article/10577-eng.htm).

While I agree that delaying pregnancy is a tool towards poverty reduction, let’s be frank: only the redistribution of wealth will eradicate poverty.

The second issue in terms of the counselling process is STI prevention and treatment. Like women who use oral contraceptives, women who use IUDs, injections (and implants in the US) may not see the need for condom use. I would like to know if they discussed and offered testing and treatment for STIs like chlamydia, the rate of which is especially high in older adolescents and young women. Because there are no symptoms of chlamydia in the majority of cases, without testing, women may contract Pelvic Inflammatory Disease which, if undetected over time, may lead to infertility – not a recommended form of birth control.

A Public Health map of Toronto that plots adolescent pregnancies follows the same geographical trajectory as STIs in the city, which, in turn, follows the curve representing its poorest neighbourhoods.

Poverty reduction, like unplanned pregnancy to young and poor women, is also complex. There are no magic wands, but there are proven tools. If we take the lead from developed countries where there is more economic equity, we see that a higher minimum wage and/or guaranteed income, a fair tax system where the wealthy and corporations paid their fair share and increased services, results in a profound reduction in poverty.

In the meantime, contraception and birth control, including post-coital options and abortion, should be freely available to all as a public health service.

Additional reading

The hidden epidemic: A Report on child and Family poverty in Toronto, November 2014

In preparation for some upcoming workshops, I’ve been learning more about barriers to healthy sexual functioning, including age, disability and eating disorders. For this month’s blog, I am focusing on eating disorders and trying to understand the complex physical, emotional and psychological issues involved. The literature is extensive and theories about causation abound; but there is less written about their effects on sexual functioning.

What is food preoccupation, how common is it, when does it become a concern and how does it affect relationships and sexual health?

If considered on a continuum, food and weight preoccupation runs from concern about weight to compulsive dieting to compulsive over-eating to anorexia nervosa and bulimia nervosa. Eating disorders such as anorexia, bulimia and binge eating can persist for years, even an entire lifetime. An estimated 10 per cent of individuals with anorexia nervosa die within 10 years of their first episodes. In 2002, 1.5 per cent of 15 to 24-year-old Canadian women surveyed had an eating disorder.

Weight preoccupation can begin at an early age. Twenty-eight per cent of girls in grade nine and 29 per cent in grade 10 have engaged in weight-loss behaviours. Thirty-seven percent of girls in grade nine and 40 per cent in grade 10 perceived themselves as too fat. Even among students of “normal-weight” (based on BMI), 19 per cent believed that they were too fat, and 12 per cent of students reported attempting to lose weight (see Public Health Agency of Canada information).

How does weight preoccupation affect sexual functioning?

While there is a big gap between a perception that one is “too fat” and abehaviour that is compulsive, it is a truism that media images feed in to girls’ and women’s desire to be thin. In the general population, negative body image can affect self-esteem and the ability to enjoy one’s sexuality. Body image issues that plague many of us are clearly magnified for women with eating disorders. But the physiological effects go much deeper.

A study published in 2010 found that nearly two-thirds of women with eating disorders reported loss of libido and sexual anxiety.

“One consistently observed finding across sexual functioning domains was the association between low lifetime minimum BMI and loss of libido, sexual anxiety and sexual relationships. These findings are consistent with the explanation that low body weight impairs the physiological functioning of sexual organs…”

The researchers conclude that “independent of physical changes, individuals with lower BMIs experience a more severe presentation of the eating disorder” which “may be associated with more profound body dissatisfaction, distortion, depression and discomfort with physical contact, all of which may be associated with loss of libido and elevated sexual anxiety…” In other words, sexual intimacy is a fundamental aspect of healthy relationships that can be disrupted by an eating disorder.

How does dissatisfaction with one’s body and low self-esteem evolve into a full blown compulsion with its associated effects on sexuality?

We understand from the literature that women with eating disorders primarily seek to have control over their bodies. What triggers this loss of control?

A controlling family, a traumatic series of events like sexual trauma and even the arrival of puberty may all contribute to a feeling of lost control.

For someone living in a controlling family, for example, food intake and weight are areas of their life they believe they can bring under their own control. Anorexia may be triggered by this realization. The National Eating Disorder Information Centre (NEDIC) sees control as the “central paradox.”

Faced with high social expectations and a “shaky sense of self,” a woman assumes that she can at least gain approval by being thin. The ideal thin body holds promise. But controlling the body becomes a precarious substitute for real control in her life. “Women feel in control of their lives through controlling their bodies, yet the need to establish this false and precarious control suggests they are desperately out of control.

Another potential trigger is childhood sexual abuse. Mary Anne Cohen suggests women who were sexually abused as children may develop an eating disorder because of guilt, shame or self-punishment. She says sexual abuse survivors may also be trying to de-sexualize themselves—becoming either tiny and childlike or obese. They may try to make their bodies “perfect” and thus “more powerful, invulnerable, and in control, so as not to re-experience the powerlessness they felt as children… Some survivors of sexual abuse areafraid [my emphasis] to lose weight because it will render them feeling smaller and childlike… Binge eating, purging or starving then becomes their ongoing self-induced punishment.”

How does this loss of control and attempt to regain it play out in a relationship aside from the physiological factors described above?

A woman who is preoccupied with her relationship with food, may be less likely to develop the skills that are essential for successful intimate relationships, including maintaining her status in a relationship as well as her ability to negotiate sexual activities and safety. Women who feel powerless; i.e., have lost control, may be less likely to be able to protect themselves from emotional or sexual abuse or from unsafe sexual practices.

If we are desperately attempting to control our bodies, we may feel ashamed of our “imperfections.” Then how can we believe someone loves us? How can we be honest with a lover when we practise secretive behaviours? How can we demand respect or communicate openly? How can we say what we want sexually, what we prefer not to do sexually and insist on sexual safety?

Treatment for women with an eating disorder will, like treatment for substance abuse, need to examine root causes—if they can be identified—as part of their treatment. The upside is that for women who recover, the prognosis for their sexual lives is positive.

I like to imagine a woman who learns to accept her body, to see it as attractive, and begin to take pleasure in it. I imagine her learning to share her body with another for mutual pleasure and admiration; and I imagine her gradual return to herself along with the desire, and ability, to love and take care of herself.

According to the website Eating Disorders Recovery Today: “in general, interest in, and pleasure from, sexual activity has been shown to decrease at the onset of the disorder and increase during weight restoration. Several explanations for this change in libido are a return to natural (and normal) hormone levels during weight restoration, and the women’s growing comfort with body acceptance and expression during recovery.” It is clear that the effects of an eating disorder are not only psychological and emotional, but physiological as well.

So the good news is, sexual health can be restored. The bad news is, eating disorders and weight preoccupation in general are increasing. We have work to do.

The other day I received a last minute phone call from CBC Radio Canada asking for an interview. The journalist said the story concerned grade 7 and 8 students sending naked pictures; and that there had been some discussion about potential child porn charges. I hadn’t heard or read anything about it and didn’t have time to prepare for an interview or come down to the studio. The story didn’t appear until a few days later: http://www.thestar.com/news/gta/2015/04/18/waterloo-region-kids-involved-in-child-porn-investigation.html. Based on what she told me, I did make a few comments, including the low numbers of adolescents sending naked photos. These are US stats from my files on its prevalence:

The American Pediatric Society stated in 2011 that “estimates varied considerably depending on the nature of the images or videos and the role of the youth involved. Two and one-half percent of youth had appeared in or created nude or nearly nude pictures or videos. However, this percentage is reduced to 1.0% when the definition is restricted to only include images that were sexually explicit (ie, [sic] showed naked breasts, genitals, or bottoms). Of the youth who participated in the survey, 7.1% said they had received nude or nearly nude images of others; 5.9% of youth reported receiving sexually explicit images. Few youth distributed these images” (http://pediatrics.aappublications.org/content/early/2011/11/30/peds.2011-1730).

I also commented on the senselessness of applying laws on child porn (or “child sexual images”, the term preferred by people in the field) to this case. But according to the article, some grade 7 and 8 students in Kitchener-Waterloo are indeed “under investigation” for allegedly being in possession of child pornography and could face charges”. However, local police are looking at it more as an opportunity to educate, a strategy with which I wholeheartedly agree.

And yet, I cannot help reflecting on the suicides these past few years provoked by public humiliations, including posts of sexual assaults – a far cry from sexting, which some researchers have referred to as a contemporary form of spin the bottle (http://www.newswire.ca/en/story/485407/-sexting-just-a-modern-version-of-spin-the-bottle). In the Waterloo case, there were “reports of nude photos being used as a “manipulation tool”. Unlike the majority of sext messages with partially nude images, “some of the images were allegedly ‘frontal nude photos,’” and at one point, the photos were posted to Facebook”.

Apparently, these young students had started out having fun – which was mutual – but ended up using the images as blackmail.

When and how do you start teaching kids why this is not OK?

As you have read ad nauseum in these blogs, sexual health education starts at home and must continue throughout students’ schooling. While it is laudable to teach children about safe (and respectful) Internet use as part of their health and physical education curriculum, if they are not taught explicitly about sexual abuse at an early age and do not understand the potential sequelae of sexual trauma, they will not develop empathy for people who suffer these traumas. Nor will they disclose abuse and receive the therapy they need to heal.

While it is difficult enough to teach children the importance of disclosing sexual abuse – that is, the negative side of sexuality – for some parents it is equally difficult to teach about positive sexuality. This is where sexual health educators step in. Given the opportunity, parents can easily brainstorm a list of what they understand to be a sexually healthy person. In my workshops on raising sexually healthy children, parents’ lists always include respect of self and others as well as communication – the ability to say yes and to say no. Children can be taught these principles from an early age. They are the building blocks of consent and empathy. The school is their partner in this critical education.

Aside from laying charges, the state has an education and advocacy role to play. The Ontario government recently launched a campaign against sexual violence with these ads: http://www.ontario.ca/home-and-community/we-can-all-help-stop-sexual-violence). One includes a scenario which I have often described in the classroom: When you send a sext message and/or photo, you never know who is on the receiving end. I remember discussing this point with a group of young people in a shelter. I asked if they had ever received a sext message. One participant took his cell out to read us one he had just received, nicely illustrating my point.

The law cannot go very far in addressing the education piece. It is the parents and the Waterloo Region school board that have their work cut out for them. One hopes they are up for the task.

The risk of developing alcohol or marijuana “dependence disorders” for young people is linked to the number of sex partners they have, according to a recent article published in the Archives of Sexual Behavior.

The researchers say that alcohol and marijuana use may encourage sexual behaviour.

There’s a shocker. The reason they link multiple sex partners and later substance abuse is because they are both part of a cluster of risk-taking behaviours that happen in adolescence and young adulthood. The association in the research was stronger for women. They added that the alcohol industry encourages the view that alcohol is entertainment, and that young women are encouraged to keep up with the boys.

The study was done in New Zealand where the ads for alcohol mirror our own in their intent. Ann Dowsett Johnston in her article “Women and Alcohol: To Your Health?” published in Network magazine refers to Mike’s Hard Pink Lemonade, Smirnoff Ice Light, wines like MommyJuice and Stepping Up to the Plate, berry-flavoured vodkas, Vex Strawberry Smoothies, coolers in flavours like kiwi mango, green apple, wild grape; and alcopop, also known as the cooler, “chick beer” or “starter drinks.” Judging from the statistics of alcohol consumption for young women, the ads have been very successful.

While the Archives article also discusses anxiety and depression, what interests me is the notion of “risk-taking behaviours.”

People who lack the basics for good health tend to have risky health behaviours, like tobacco and alcohol abuse. So do people who are survivors of sexual abuse.

The researchers had taken prior mental health status into consideration in the analysis of their findings. I doubt that they would consider child sexual abuse to be a mental health disorder; but of course it can provoke mental—and even physical—disorders. The body remembers even what the mind prefers to repress. For youth accessing treatment for both addiction and mental health problems at the Toronto Centre for Addiction and Mental Health (CAMH), it is frighteningly common for them to have histories of traumatic stress as well as sexual abuse.

I met Laura (not her real name) when she was 11. She was a student in a Grade 6 class I was teaching about puberty. In those days, I spent six hours with each Grade 5 and 6 group, so I got to know the kids pretty well. I always ended with a session on sexual abuse. I remember listening to Laura’s teachers in the staff room. They were talking about her, making remarks akin to teenage boys’ comments about high school girls with a “reputation.” After the class on sexual abuse, Laura disclosed to me that she had been gang raped at nine and had been in an alcohol daze ever since. I should have figured it out from the teachers’ remarks. Precocious sexual behaviour can be a marker of sexual abuse.

I put Laura in touch with a child protection agency. A few years later, I saw her regularly in a sexual health clinic and eventually encouraged her to go into therapy. During her adolescence, Laura still abused alcohol and other drugs and was sexually assaulted more than once. I would accompany her to the sexual assault care centre to hold her hand.

A colleague of mine at the time said there was no point in treating substance abuse unless you dealt with the root causes first. She had expertise in both, professionally and personally.

Similarly, adolescent pregnancy is not as simple as asking why teens just don’t use condoms. Health professionals can plot adolescent pregnancies on a city map and see the links with lower socio-economic status. In other words, risky behaviours do not exist in a vacuum. They are linked to basic needs: food, shelter and freedom from sexual violence and racism.

Substance use, aside from being big business, serves multiple purposes. Alcohol removes inhibitions, which makes it the most common drug used for date rape. Alcohol and other substances including tobacco are used to self medicate. Dowsett Johnston says, “the strongest predictor of late onset drinking is childhood sexual abuse.” Laura was self-medicating throughout her adolescence: she was dulling the pain of a traumatized life. While the research may show an increase in substance abuse afterhaving multiple partners, in Laura’s case—and for many women who are sexually abused as children—substance abuse came first.

In workshops, when we ask parents when sexuality education should begin, they often answer “age 10, 12 or more.” But it doesn’t take long before someone in the group will point out that it’s much too late. With some girls beginning puberty at age seven, and sexual images at every turn, we need to reconsider.

Sexuality begins at birth; even in the womb a male fetus will have erections. The moment a baby is born and held, the lessons have begun. “Someone who loves me is holding me. I like getting my back stroked. Is that a nipple in my mouth? Oh, heaven.”

Changing a baby, we talk to them. This is a great time to start using dictionary words for their genitals such as penis and vulva instead of wiener and flower. Building a vocabulary opens the door to communication about sexuality as they grow.

A six-month-old is likely to discover their genitals. How parents react to this may vary greatly; but the message needs to be clearly thought out. If you say, “Don’t touch!” you are telling them it is not okay to have access to that part of their body, and that the pleasure they feel is not okay. If you let them explore, they are learning about the pleasures of the body, and that every part belongs to them. There will be time for them to learn that it’s not okay to have that pleasure in the supermarket.

They may accept their gender, which is congruent with the way they look, or they may not. Current research suggests that parents/guardians should take the lead from the child when there is dramatic variation in their gender behaviour.

Sexual exploration (playing house, doctor, etc.) with other children often starts around age three. It is very common. Some parents/guardians wonder about the difference between expected and unexpected sexual exploration. For those who were sexually abused as children, they may feel even more protective. An important message is that there should never be any secret touching. Children also need to know that if they have that “uh-oh” feeling, they need to tell you. If a child reports unusual sexual behaviour with another child or with someone older that concerns you, call your local child protection agency for advice. (See: www.boostforkids.org for more information.)

By this age, children are also asking questions. The rule of thumb is: answer what they ask in age appropriate terms. Include your parental message along with the factual information. For example, an answer to, “What are balls for?” may be, “They’re called testicles. They make sperm. When you grow up, if you want to make a baby, that’s what you’d need.”

You may also want to find out what they already know. So when a child asks where babies come from, you may want to ask, “Where do you think they come from?” and work with their information.

If an older child asks, “When can I have sex?” your answer may be rooted in simple physiological facts, your religious values or your personal politics.

In part two, I’ll write about some key issues for children up to nine and then some more for children going through puberty.